Provider Demographics
NPI:1922160845
Name:SISIRA GUNAWARDANE MD INC
Entity Type:Organization
Organization Name:SISIRA GUNAWARDANE MD INC
Other - Org Name:FAMILY MEDICAL CENTER OF WEST COVINA
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:SISIRA
Authorized Official - Middle Name:K
Authorized Official - Last Name:GUNAWARDANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-960-5461
Mailing Address - Street 1:333 N SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790
Mailing Address - Country:US
Mailing Address - Phone:626-960-5461
Mailing Address - Fax:626-962-7199
Practice Address - Street 1:333 N SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790
Practice Address - Country:US
Practice Address - Phone:626-960-5461
Practice Address - Fax:626-962-7199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0095500Medicaid
CAGR0095500Medicaid